Breast Reconstruction

When facing breast cancer diagnosis, women focus all their efforts on therapeutic strategies. Most of them develop a personal conflict between what is required to eradicate the tumor and the fear of remaining mutilated. Some others remove or postpone this fear to “later”, even though they agree on the importance of body image for an optimistic continuity of the cures, facing at future.

Breast reconstruction includes a series of procedures having the goal of restoring a natural-like breast as similar as possible, in shape and volume, to the patient's own breast before surgery.

An important aspect of breast reconstruction is its “immediate” accomplishment, contemporary to the general surgeon's mastectomy where the tissues affected by the tumor are removed. It can also be performed as a “delayed” procedure, wherein reconstruction is achieved in a later stage following healing from mastectomy. It is worldwide recognized  that immediate breast reconstruction is much better for the patient, and for her well-being, because it reduces the trauma for the amputated organ and relieves the woman from living for several months in a body that she feels incomplete.

There are several clinical situations requiring a breast reconstruction: phisician call it “radical” mastectomy if resection includes the whole breast gland with overlying skin, “nipple sparing” if only the gland is removed saving the skin with nipple and areola, and “skin sparing” when the gland with the nipple and areola complex are removed saving the breast skin only.

In these cases it is correct to speak of traditional breast reconstruction. 

There are then other circumstances in which it is possible to remove the tumor by resecting only one of the four quarters of the breast; this procedure is the so-called “quadrantectomy” with oncoplastic reconstruction.

In case of a mastectomy it is necessary to replace only the breast component removed, i.e. the breast volume with or without the skin envelope.

Concerning the skin envelope there are two possibilities: to replace the skin defect by transferring a skin flap from other areas of the body or it is possible to expand the thoracic skin remaining after mastectomy, by means of placement of an expander under the pectoralis muscle.

To reintegrate the breast volume it is possible to use autologous tissue transfer (flap) or a silicone prosthesis.

Some procedures as the DIEP or Latissimus Dorsi flap might replace both the skin envelope and the breast volume at the same time, hence achieving the reconstruction of the whole breast in "one stage".

Whenever the breast skin has been spared and only a volume replacement is required, it is possible to use autologous tissues from the patient (adipose DIEP flap without skin) but not silicone breast prosthesis.

If the available flaps to be transferred are not large enough to replace the whole breast volume, “mixed procedures" using both autologous tissues and prosthesis (Latissimus Dorsi + prosthesis or Wise pattern + prosthesis) are required. The goal is to replace the breast in a single stage, simultaneously with mastectomy.

If there is lack of donor tissues to be transferred as a flap, either to reintegrate volume or skin envelope, it is still possible to reconstruct the breast using a skin expander and prosthesis, a procedure that necessarily requires “two stages", distant from each other. At the first stage is implanted an expander, a sort of silicone reservoire that, by means of weekly introduction of saline solution, grows expanding the thoracic skin. At the second stage, few months later, the expander is removed and replaced by the definitive prosthesis.

If surgeons decide that it is possible to avoid a radical mastectomy performing qudrantectomy to remove only part of the affected gland, the remaining breast tissue can be “remodelled" as to obtain a good cosmetic result, sometimes comparable to an aesthetic procedure for breast volume reduction.

In this web site the oncoplastic approach to inferior quadrantectomy, known as Wise pattern" (from the american surgeon who firstly described it), and its variation described by Prof. Santanelli di Pompeo for reconstruction following superior quadrantectomies, are described.

It should not be excluded that, for many women, breast reconstruction with autologous tissues or with Wise pattern might end up with an improved cosmetic appearence of the breast, looking younger, stiffer and higher.

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Redazione Barbara Fabiani